Recent studies strengthen substantially the evidence that biofeedback is the preferred treatment for disordered defecation and levator ani syndrome, and identify patient characteristics that predict successful outcomes. Biofeedback does not benefit patients with constipation due primarily to slow transit, but is effective in patients with either inability to evacuate a balloon or impaired relaxation of pelvic floor muscles during straining. For chronic proctalgia, the same 2 signs plus tenderness on palpation of the pelvic floor predict success. Conservative measures, including careful characterization and management of bowel disturbances, is key to managing fecal incontinence. A new RCT carried out in patients who failed conservative management demonstrated that biofeedback provided additional benefit for fecal incontinence and was superior to pelvic floor exercises. However, other studies suggest that when patients are taught how to perform pelvic floor exercises with verbal guidance from a therapist during digital rectal examination, this may be as effective as biofeedback provided by machines. Limitations of biofeedback are the paucity of well-trained therapists and limited efficacy in children. RCTs also support the efficacy of SNS for fecal incontinence, but this is not yet approved for use in the United States. New diagnostic techniques including pelvic floor MRI have increased our understanding of the risk factors and pathophysiology of anorectal disorders. Pending approval by the FDA, sacral nerve stimulation is a new option for patients with fecal incontinence who have failed conservative therapy.
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